Provider Demographics
NPI:1679097307
Name:EMBRY-RIDDLE AERONAUTICAL UNIVERSITY, INC.
Entity Type:Organization
Organization Name:EMBRY-RIDDLE AERONAUTICAL UNIVERSITY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARIANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:BASKIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:386-226-7912
Mailing Address - Street 1:600 S CLYDE MORRIS BLVD
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32114-3966
Mailing Address - Country:US
Mailing Address - Phone:386-226-7912
Mailing Address - Fax:
Practice Address - Street 1:600 S CLYDE MORRIS BLVD
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114-3966
Practice Address - Country:US
Practice Address - Phone:386-226-7912
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EMBRY-RIDDLE AERONAUTICAL UNIVERSITY, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-08-03
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty